Postural Orthostatic Tachycardia Syndrome

Aka: Postural Orthostatic Tachycardia Syndrome, POTS Syndrome

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II. Definitions

  1. Postural Orthostatic Tachycardia Syndrome (POTS)
    1. Symptoms of Orthostatic Intolerance with Tachycardia, but not significantly hypotensive

III. Epidemiology

  1. Prevalence: 0.2 to 1% in general U.S. population
  2. Age <50 years in most cases (peaks age 15 to 25 years)
  3. Gender: Female to male ratio 5:1

IV. Symptoms

  1. See Orthostasis
  2. Symptoms occur on standing from supine (or seated position) and are relieved on returning to supine position
  3. Typically worse in mornings and chronic (duration 3-6 months) at diagnosis
  4. Dizziness or Light Headedness
  5. Chest Pain or Palpitations
  6. Orthostatic Syncope
  7. Nausea
  8. Pallor
  9. Weakness or Fatigue
  10. Dyspnea
  11. Blurred or dimmed Vision
  12. Neck or Shoulder Pain

V. Diagnosis

  1. Symptoms suggestive of Orthostasis (see above) AND
  2. Insignificant change in systolic Blood Pressure (BP decreases <20 mmHg) AND
    1. Does not meet criteria for Orthostatic Hypotension
  3. Tachycardia
    1. Sustained Heart Rate 30 bpm or higher within 10 minutes of standing (or Head-Up Tilt-Table Testing)
    2. Standing Heart Rate is typically >120 bpm
    3. When evaluating, age 12 to 19 year olds, requires Heart Rate increase >=40 bpm

VI. Differential Diagnosis

  1. Neurocardiogenic Syncope
  2. Orthostatic Hypotension

VII. Evaluation

  1. Head-Up Tilt-Table Testing

VIII. Management

  1. See Orthostatic Hypotension
  2. Maintain adequate hydration
  3. Aerobic Exercise
    1. Combats deconditioning with increased Cardiac Function and autonomic regulation
    2. Start with seated or horizontal Exercises first (e.g. recumbent bike, swimming, rowing machine)
    3. CHOP Modified Dallas/Levine Protocol
      1. https://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf
      2. Modified Levine protocol for younger patients
    4. Levine Protocol
      1. Seven month protocol of Exercise (recumbent warmup, moderate exertion, and cooldown)
  4. Other measures
    1. Sleep in head up position
      1. Expands Blood Volume
    2. Lower body compression garments
      1. Reduces venous pooling
      2. Should extend at least to the xiphoid (or with an abdominal binder)
    3. Physical countermeasure maneuvers
      1. Squeezing a Rubber ball
      2. Leg crossing
      3. Muscle pumping
      4. Squatting
      5. Negative-pressure breathing

IX. Resources

  1. Exercise with POTS: Dallas Protocol, Levine Protocol, and CHOP Protocol
    1. https://www.eds.clinic/articles/exercise-pots-dallas-levine--chop-protocols

X. References

  1. Kim (2022) Am Fam Physician 105(1): 39-49 [PubMed]
  2. Levine (2018) Auton Neurosci 215:20-7 +PMID: 30001836 [PubMed]

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Related Studies

Ontology: Postural Orthostatic Tachycardia Syndrome (C1299624)

Definition (MSH) A syndrome of ORTHOSTATIC INTOLERANCE combined with excessive upright TACHYCARDIA, and usually without associated ORTHOSTATIC HYPOTENSION. All variants have in common an excessively reduced venous return to the heart (central HYPOVOLEMIA) while upright.
Definition (NCI) A syndrome characterized by orthostatic intolerance resulting in tachycardia, often accompanied by a decrease in the blood pressure. It occurs when individuals change from the supine position to an upright position. Other signs and symptoms include lightheadedness, fainting, fatigue and muscle weakness.
Concepts Disease or Syndrome (T047)
MSH D054972
SnomedCT 371073003
Italian Sindrome da tachicardia ortostatica posturale, Sindrome della tachicardia posturale ortostatica, Sindrome della tachicardia posturale
Japanese 起立性頻脈症候群, ｷﾘﾂｾｲﾋﾝﾐｬｸｼｮｳｺｳｸﾞﾝ, Postural Orthostatic Tachycardia症候群, 体位性頻脈症候群, 頻脈症候群-体位性
English Syndrome, Postural Tachycardia, Tachycardia Syndrome, Postural, Postural Tachycardia Syndrome, Postural Orthostatic Tachycardia Syndrome, Postural Orthostatic Tachycardia Syndrome [Disease/Finding], postural orthostatic tachycardia syndrome (diagnosis), Postural OrthostaticTachycardia Syndrome, Postural orthostatic tachycardia syndrome (disorder), Postural orthostatic tachycardia syndrome
Czech Syndrom posturální ortostatické tachykardie, syndrom posturální ortostatické tachykardie, syndrom posturální tachykardie
Spanish Síndrome de Taquicardia Postural, Síndrome de Taquicardia Postural Ortostática, síndrome de taquicardia postural ortostática (trastorno), síndrome de taquicardia postural ortostática, Síndrome de taquicardia postural ortostática
French Syndrome de tachycardie posturale, Syndrome de tachycardie orthostatique, Syndrome de tachycardie orthostatique posturale, Syndrome de tachycardie posturale orthostatique, Syndrome de tachycardie en posture orthostatique
Russian TAKHIKARDII POSTURAL'NOI SINDROM, POSTURAL'NOI ORTOSTATICHESKOI TAKHIKARDII SINDROM, ПОСТУРАЛЬНОЙ ОРТОСТАТИЧЕСКОЙ ТАХИКАРДИИ СИНДРОМ, ТАХИКАРДИИ ПОСТУРАЛЬНОЙ СИНДРОМ
German Posturales Tachykardie-Syndrom, Posturales orthostatisches Tachykardie-Syndrom, posturales orthostatisches Tachykardiesyndrom
Portuguese Síndrome da Taquicardia Postural, Síndrome da Taquicardia Postural Ortostática, Síndrome de taquicardia ortostática postural
Swedish Postural ortostatisk takykardisyndrom
Polish Zespół tachykardii postawno-ortostatycznej, Zespół tachykardii ortostatycznej, Zespół tachykardii posturalnej, Zespół częstoskurczu postawno-ortostatycznego
Hungarian Posturalis orthostatikus tachycardia syndroma
Norwegian Posturalt ortostatisk takykardisyndrom, Posturalt ortostatisk takykardi-syndrom
Dutch posturele orthostatische tachycardie-syndroom
Derived from the NIH UMLS (Unified Medical Language System)

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